Tue February 11, 2014

Practicing 'Extreme Medicine,' From Deep Sea To Outer Space

Most of us have never been submerged under more than a few feet underwater. But just a few meters down, the water compresses the tissues of your body so that you become more dense. At that point, "You're more likely to sink than float," says Dr. Kevin Fong.

Kevin Fong is a co-director of the Centre for Aviation Space and Extreme Environment Medicine and physiology lecturer at University College London.

Anthony CullenCourtesy of Penguin Press

Dr. Kevin Fong works on "the edges" of medicine — researching how humans survive extremes of heat, cold, trauma, outer space and deep sea. "We're still exploring the human body and what medicine can do in the same way that the great explorers of the 20th century and every age before them explored the world," he tells Fresh Air's Terry Gross.

In his book Extreme Medicine, Fong describes how avant garde medicine is challenging our understanding of how our bodies work and the boundary between life and death.

"You're taking this headlong plunge into the unknown hoping only that good fortune and survival might lie in wait," he says.

Interview Highlights

On administering medicine in space

Almost everything you take for granted in everyday medicine doesn't work there. The first thing I do when I go see a patient is I walk up to their bedside and say, "Hi, how are you? What seems to be the problem?" And of course, even doing that you can't do in space because your patient is floating, so you have to manage that situation, just for starters. Usually that involves Velcro-ing them to the floor or the vehicle.

... There's so much of medicine that depends on gravity. You know, the drips that they stick in your arm to rehydrate you? That is a gravity-dependent process. All the kits that you would unpack, that stuff doesn't stay on the trays, you've got to find ways to pack that stuff, the drugs, the needles, the scalpels, and all of that so it doesn't end up floating around. So just the basics need addressing and then you've got to start getting into the nitty-gritty of what the space environment does to the human body and how that's going to create an even greater challenge as a physician.

On how uncomfortable it is to be in outer space

When you see space men and women on television you get this impression that it's sort of like a slightly more fun version of a super long-haul passenger flight that, you know, it's a quite comfortable experience and they're just floating around there having quite a lot of fun while engaging in quite a serious task. But when you get down into it, you realize that these expeditions are true expeditions — expeditions really in the same sense that walking into the deserts or climbing our highest mountains, or exploring our polar regions are — that you go into this environment and you learn the same lessons from it that you learn everywhere else in exploration, and that is that we can exist there, but not forever and not without penalty.

[Due to lack of gravity] they experience [the] wasting of their bones, wasting of their muscles, deconditioning of their heart ... They have problems with their hand-eye coordination. It seems that the apparatus in your inner ear that detects acceleration — that helps you with your day-to-day hand-eye coordination — also gets pretty messed up up there, and so they have problems tracking moving objects with their eyes, and ... they feel pretty sick. In fact, most rookie astronauts feel sick or are sick in the first 24-48 hours of flight. So when you see them up there on-camera, waving and smiling at you, you have to know that underneath that is a lot of discomfort for lots of them.

On the "negative buoyancy" you start to experience when you are just a few meters underwater

Most of our experience of the water and all the ocean is limited to literally a couple of meters from the surface. So we feel this sensation that the water wants to throw us back out. It's hard. It takes effort to dive below the surface, doesn't it? And very few of us really dive to any depths at which that relationship changes. But what happens is, as you dive into the water, the water around you starts to compress the tissues of your body so that you, yourself become more dense. After you've gone maybe only — depending on your build and what you're wearing — maybe seven, eight meters from the surface ... you are no longer buoyant. You will no longer float. You're more likely to sink than float. So after that point you become negatively buoyant, which is to say that you sink.

So the problem is, if you're in a vehicle that has crashed or is sinking and you are more than a few meters — a handful of meters under the surface — you're going to be more likely to sink than float. This causes huge problems if you're in a vehicle and there's no source of illumination. So if you're in there at night and you have this horrific realization that if you find yourself below about 10 meters at night with no light to show you the way, you're not going to have an idea of which way to swim and you're just going to have to choose a direction, and if you choose the wrong direction, you're going to swim for the rest of your life, quite literally.

... Suddenly, you have a new respect for both these things that you're traveling in over water, the ocean itself, and you realize how hostile that is as an environment. It's not there to support us. It's pretty inimical to human life, really. We're not supposed to be in it, we're only just about to be on it.

On what to do if your helicopter crashes into the ocean

Yes, they put you in a thing that looks like a helicopter. And you are strapped in and you go into water and the first thing you think to do is ... unstrap and try to get out. Problem with that is [there is] water all around the opening and you will get lost and never make it out. You will never find a way to exit. Counter-intuitively ... you are supposed to sit and have one hand on [the] seat and [the] other on the exit — preferably on the window you will swim out of — and wait for all motion to cease. Til you are really sinking; and when that happens, open window, pull seat buckle apart and pull yourself out of the window. It takes discipline to resist the urge to get yourself out there, but that is the difference between life and death in that situation.

On what your body is doing to try to prevent you from freezing to death

Just before you freeze to death you mount this sort of final effort to try and save your life, and so you try and centralize the heat to the core of your body. Your blood vessels constrict to try to stop you [from] losing heat from your periphery — from your arms and from your legs — and then ... your hairs stand on edge. It's one of the reflexes we have, trying to trap an extra layer of air to insulate your body ... but all of this, is your body mounting its last attempt to keep itself alive. It does everything it can. ... It's to buy you extra time.

The hypothermia is a double-edged sword here, because it conspires to run the batteries of life down ... and that's what stops your heart. That's what leads to cardiac arrest, but also it protects the brain. So although it kills you, it smears out the dying process.

... We think of death as being a moment in time, but actually, it is a process. And that process is usually relatively quick, it's completed in a few minutes under normal conditions, but here, with these extremes of cold ... what that does biologically, it takes the process of death ... and extends it to minutes, [and in Bågenholm's case] it smeared it out to be hours long. Long enough, that they might intervene, restore the supply of oxygen to her brain, start her heart again, and get someone back who resembles who she was before the accident.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

Transcript

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. Our understanding of how our bodies work and of the nature of the boundary between life and death are being challenged by avant-garde medicine, writes my guest, Dr. Kevin Fong. In his new book "Extreme Medicine" he explains what medical science has learned about surviving extremes of heat, cold and trauma, as well as the extreme conditions of outer space and the deep sea.

Fong is an anesthesiologist who's also trained in intensive care medicine. He's the founder of the Center for Altitude, Space and Extreme Environment Medicine at the University College London, where he's also a professor of physiology. He's the former chair of the U.K. Space Biomedical Advisory Committee.

Dr. Kevin Fong, welcome to FRESH AIR. Let's start with space medicine. What are some of the things you can't do medically in zero gravity that doctors are used to doing on Earth?

DR. KEVIN FONG: Well, you know, the thing is, and the thing I came to realize when I worked out with the guys at NASA ,was almost everything you take for granted in everyday medicine doesn't work there. You know, the first thing I do when I go and see a patient is I walk up to their bedside and say hi, how are you, what seems to be the problem. And of course even doing that you can't do in space because you're floating, your patient's floating. So you have to manage that situation just for starters.

So usually that involves Velcroing them to the floor of the vehicle and Velcroing yourself to them.

(LAUGHTER)

FONG: Or strapping yourself down near them. And then, you know, there's so much in medicine that depends upon gravity. You know, the drips that they stick into your arm to rehydrate you, you know, that is a gravity-dependent process. But all of the kits that you would unpack, you know, that stuff doesn't stay on the trays. You've got to find ways to pack that stuff, the drugs, the needles, the scalpels and all of that so it doesn't end up floating around.

So just the basics need addressing, and then you've got to start getting into the nitty-gritty of what the space environment does to the human body and how that's going to create an even greater challenge for you as a physician.

GROSS: What are some of the most typical health problems that astronauts who are spending time in space experience?

FONG: Well, you know, it's funny because when you see spacemen and women on television, you get this impression that it's sort of like a slightly more fun version of a super-long-haul passenger flight, that, you know, it's a quite comfortable experience, and they're just floating around there having quite a lot of fun while engaging in quite a serious task.

But when you look down into it, you realize that these expeditions are true expeditions, expeditions really in the same sense that walking into the desert or climbing our highest mountains or, you know, exploring our polar regions are, that, you know, you go into this environment, and it's the same - you learn the same lessons from it that you learn everywhere else in exploration, and that is that we can exist there but not forever and not without penalty.

And they experience everything from a wasting of their bones, wasting of their muscles, wasting really - deconditioning of their heart because their heart itself is a muscle pump, all of this because of the lack of gravitational load, the lack of the force of gravity upon their bodies.

And then there's some stuff that you wouldn't really readily predict. They have problems with their hand-eye coordination. It seems that the apparatus in your inner ear that detects accelerations, that helps you with your day-to-day hand-eye coordination also gets pretty messed up up there. And so they have problems tracking moving objects with their eyes.

And also on top of that they feel pretty sick, and in fact most rookie astronauts feel sick or are sick in the first 24 to 48 hours of flight. So when you see them up there on camera waving and smiling at you, you have to know that underneath that is a lot of discomfort for lots of them.

GROSS: So we've talked a little bit about, you know, studying medicine in space. But you've also worked with deep sea diving medicine. And that puts a completely different set of pressures on the body being underwater. What are some of those pressures?

FONG: Well, you know, when you look at the envelope that supports life around the Earth, it's remarkably thin. And when you're talking about diving, and if you put a tank of air on your back, if you get in the water and you dive maybe 10, 20, 30 meters down, you start to experience problems just with the effects of pressure on your body and what that does to the air that you're breathing.

And so, you know, at 30 meters depth, you can get drunk on the nitrogen in the air that you're breathing, which is really quite a remarkable thing, that a normally inert gas can play havoc with the way that your brain works, you know, even at that shallow depth of penetration into that sphere. So this is just, you know, this is close enough to the surface that you can see the surface above you rippling overhead, but it's changing you, and it's changing the things that you're doing.

In addition to that, you know, you get these gases dissolving in your bloodstream, and so subtly changing your physiology, changing your biology so that you're adapting to this new environment, but at the same time you're storing up problems for when you return. And so for those people who are involved in, you know, recreational diving, we all know that you have to have this very strict time limit on how long you spend at depth, and you have to very carefully return to the surface gradually so that you don't - those bubbles of nitrogen don't just fizz out of solution and cause you problems, cause problems with decompression illness or things that we more commonly refer to as the bends and illnesses related to that.

And I've always thought it was quite remarkable that, you know, the layer that supports human life around the Earth is probably about - you know, breathing room air is probably about, you know, 10, 20 meters into the ocean, breathing air, and probably no more than about 9,000 meters if you're going up a mountain.

GROSS: You tell this great story of something that happened to you in your chapter about underwater medicine. And you were trained in escape training underwater. This is the Royal Navy's Helicopter Underwater Escape Training Facility. And the goal here was to teach you how to escape from a helicopter that has crashed in the ocean.

FONG: You're submerged and you have to get out. And there's some amazing things about what happens to the body underwater and why everything that you have to do is totally counterintuitive if your helicopters crash. So can you talk about that negative buoyancy?

Yeah, so, you know, most of our experience of the water and all the ocean is limited to a couple - literally a couple of meters, you know, from the surface. And so we feel this sensation that the water wants to throw us back out. You know, it's hard, it takes effort to dive below the surface, doesn't it?

And very few of us really dive to any depth at which that relationship changes. But what happens is as you dive into the water, the water around you starts to compress the tissues of your body so that you yourself become more dense. And after you've gone maybe only, depending on your build and what you're wearing, but maybe seven, eight meters from the surface, so you know, a very modest distance, you are no longer buoyant.

That is, you will no longer float. You're more likely to sink than float. And so after that point you become negatively buoyant, which is to say that you sink. And so the problem is, if you're in a vehicle that has crashed or is sinking, and you are more than, you know, a few meters, a handful of meters under the surface, you're going to be more likely to sink than float.

And this causes huge problems if you're in a vehicle and there is no source of illumination, so if you're in there at night - and you have this horrific realization that if you find yourself below about 10 meters at night with no light to show you the way, you're not going to have an idea of which way to swim, and you're just going to have to choose a direction.

And if you choose the wrong direction, you're going to swim for the rest of your life, quite literally.

GROSS: Yeah, because you'll just be swimming deeper and deeper instead of up?

FONG: That's right, so you know, when you're in a swimming pool...

GROSS: Or just swimming to the side. I mean, I guess you wouldn't know up, down, left, right.

FONG: There is no side. You're in a vehicle that may have turned upside-down. It's very difficult to know what's up and what's down. You are - you know, when you're in a - our common experience of swimming is at very shallow depths. And when you're swimming around, you know, you feel that you want to be taken back to the surface. If you do nothing, mostly, you're going to find yourself back on the surface.

And that is not true after a very, very shallow excursion beyond those very modest steps. And suddenly you have a new respect for both, you know, these things that you're traveling in over water, the ocean itself, and you realize how hostile that is as an environment. And it's not there to support us. It's, you know, pretty inimical to human life, really. We're not supposed to be in it. We're only just about supposed to be on it.

GROSS: So you describe, you're in a test facility, in basically a large warm pool, very large warm pool.

FONG: Yeah, it was at the time, yeah.

GROSS: And you're in this, like, submerged helicopter learning how to escape. This is like a training experience for if this happens in the ocean.

FONG: In this training operation, they put you in this thing that looks pretty much exactly the sorts of helicopters that may take you from the shore to an oil rigger. And you're strapped in with a - in my case I think it was a five-point harness. And then you go into the water.

And so the first thing that you think that you would do if you're in a vehicle that is sinking, and the water's pouring in the windows is, well, you'd unstrap from your seat, and you'd try and get out. But the problem with that is you've got such a current of water coming in through all the openings that if you do that, you're just going to get washed around inside this vehicle as the vehicle itself turns over and starts sinking.

And you're going to get disorientated. You're going to get lost inside this vehicle. You're probably never going to make it out because you'll never find your way to an exit. So counterintuitively what you're supposed to do is to sit there and have the presence of mind to put your hand - one hand on the buckle of your seatbelt so you know how to undo that, and the other hand on an exit, preferably on the handle that's going to eject the window that you're going to swim out of.

And then you're meant to wait. And I think the phrase they use is to wait for all violent motion to cease, which is basically them saying wait until you're really sinking, and everything's stopped moving. And then once that happens, then you're meant to eject the window, hold onto the window frame and then pull your seat buckle apart and pull yourself out of the window.

It takes quite a lot of discipline to resist that urge just get the hell out of there from the word go, but that is, that becomes, the difference between life and death in that situation.

GROSS: How did your body and your mind fight each other when your body was saying get me out of here, and your mind was saying, no, I have to sit still, I have to wait until it turns upside-down, I have to wait until I'm totally immersed in water?

FONG: You know, it is completely - if no one had told you what to do, you would've done completely the opposite. You wouldn't unbuckled from your belt the minute that you saw the water coming in the sides, and I think that would have been the end of you. I mean they show you very graphically that that is not the right thing to do.

And so what you realize is that in those situations, your life depends on a sequence of fairly simple, massively counterintuitive steps that protect you from yourself, really, in that situation. And so the key to it is just listening to what your instructor is telling you and to believe, to have faith in them that that's the right thing to do.

And once you do that, once you get used to that, once you can overcome your overwhelming sort of panic response to think, well, surely the less time I'm in this vehicle the better, then everything's OK, and it's actually almost, almost calm. But they do show you, you know, they do show you beforehand, they show you videos of sort of these young, I guess they're young airmen from the Royal Air Force or from other branch of the armed services who haven't listened.

And the thing goes in, the thing goes upside-down. They unbuckle. They get lost, and they find themselves swimming around in the dark, unable to find their way out before an instructor hauls them out, you know, very heavily through the window. So you know you don't want to do that.

GROSS: So when you finally at that last minute pull the release and undo your safety belt, how do you know which way to swim?

FONG: Yeah, that's a great question. So, you know, if it's daylight, and there's still some light around, you know, you're supposed to watch for bubbles and watch the bubbles rising and follow the bubbles. If it's nighttime, you hope that it's a clear night, and you might see some illumination, you know, moonlight perhaps through the surface.

But, you know, it is possible that it is a deep, dark, black night, and you're swimming out into the inky blackness, and you just don't know, and you're just going to have to choose a direction. And there are accounts of these sort of - accounts from sailors with these terrifying stories of them swimming out into the inky blackness, not knowing, and swimming and swimming and just hoping that they've chosen the right way and hoping that it's going to take them up to the surface.

GROSS: I know among the many things that you do is you practice emergency anesthesia medicine in a helicopter trauma unit, which is where you were last week, flying around. Do you expect you'd ever need to use this emergency training?

FONG: Well, I hope not, but you know, I think a lot of the stuff I've done has given me a fairly healthy respect for things that I guess we take for granted and certainly respect for the physical environment around us. And helicopters are amazing vehicles, but they are quite fragile, and they are prone to accident. So you can't rule out the possible that flying over water one day you might have some catastrophic failure of the vehicle. So you've got to be prepared for that, I guess.

I mean the vehicle that I fly in actually doesn't fly over great expanses of water, but you know, for anyone who travels in these vehicles, you know, and for anyone who's ever traveled in a helicopter, your - actually your first emotional response is usually one of excitement. But it should be, should be more rationally one of gentle trepidation.

You know, there's a lot of moving parts. There's a lot to go wrong. And sometimes it does. So you know, it's worth respecting that mode of transport.

Well, all the fear of flying people in our audience feel very validated by what you just said.

(LAUGHTER)

GROSS: If you're just joining us, my guest is Dr. Kevin Fong. He's the author of the new book "Extreme Medicine." He's also the founder of the Center for Altitude, Space and Extreme Environment Medicine at the University College London. Let's take a short break, then we'll talk some more. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: If you're just joining us, my guest is Dr. Kevin Fong. He's the author of the new book "Extreme Medicine," and he's the founder of the Center for Altitude, Space and Extreme Environment Medicine at University College London, where he teaches physiology. He's also a consultant in anesthesia and intensive care medicine.

So among all the things that you do, you're an anesthesiologist. And you tell a very funny story about another anesthesiologist who was being interviewed for a position at a hospital and was asked how do you see your job. Would you just tell us the punch line there? Because it's hysterical.

FONG: So it's funny, isn't it, because, you know, our popular imaginings of anesthesiologists is, you know, they sort of sit at the end of the table and do what the surgeon tells them to do, and occasionally they sneak off and do the crossword when they're a bit bored, when in fact it's much more dynamic role than that.

And indeed it's very challenging because you're sitting there trying to look after the patient's physiology and stop, you know, counteract the effects of the drugs they're using or the blood that the surgeon is releasing. And so a colleague of mine interviewed for a job with a cardiothoracic team, so a bunch of heart surgeons.

And in that interview, one of the slightly pompous heart surgeons says, listen, I want to know what you think you can contribute to this team, what you think you can contribute to this heart surgery. And my colleague sort of sat there and said, well, that's easy. It's like flying a plane. I fly the plane, and you provide the in-flight entertainment.

And I think that is pretty much the relationship we have with our surgical colleagues, I think.

GROSS: So in what sense is the anesthesiologist flying the plane?

FONG: Well, so I think, you know, anesthesia is a very subtle thing, really, because - you know, and it's a thing of great trust. The patient comes to you, and you wrest control of their physiology, their biology from them temporarily. You send them to sleep, and you take over much of the automatic function of their body.

Many of the things that the body usually controls by itself automatically, you are asked to come in and at least regulate and monitor and intervene on things like blood pressure and heart rates and even temperature. And so you are their - sort of the patient's advocate, if you like, protecting them, wrapping them in this sort of cocoon of protection that you build with the drugs that you have, your knowledge of the drugs and their effects on their body, and you resuscitate them.

And you know, in the biggest operations you are sitting there actively resuscitating the patient from the insult that is surgery. And don't get me wrong, the surgeons do a wonderful job, but that insult is necessary, but it's an insult nevertheless that they need to be protected from, and that's part of the anesthetist's role.

GROSS: Have you been under anesthesia?

FONG: I have, actually, yes. I had my appendix out before I was - in fact, before I was a medical student. And it's funny, you know, looking back it later on and realizing what was going on because at the time I just had no idea. So yes, I've had anesthesia myself.

GROSS: Was it lucky that you didn't know? Would you be more uncomfortable now?

FONG: I don't know. I think it depends on who was giving me the anesthetic, actually.

GROSS: Right, and that's the thing. We don't know. Like we choose our surgeon, we choose our doctor to the best of our abilities. Like let's find the best surgeon to do this. But you don't hear many people saying and let's find the best anesthesiologist. You just kind of take that for granted.

FONG: Yeah, I mean, you know, you're right to try and choose the best surgeon because the best surgeon with the best hands is probably going to give you the best chance. But, you know, it's gone past the point where surgery is really about the person with the best pair of hands and the best knife. These are real team sports.

You know, it's a little bit like watching, you know, a live band onstage. Yes, all eyes are on the lead singer, but, you know, you want to have a good bass guitarist and a good drummer in there somewhere, otherwise the whole thing's going to come apart. So, you know, we love inventing this narrative of the lone superhero, but actually, you know, I'm not sure that they really exist in modern medicine.

You know, what you should be looking at, the complexity and the performance of the team as a whole, in which the anesthesiologist is a very integral part.

GROSS: Dr. Kevin Fong will be back in the second half of the show. He's the author of the new book "Extreme Medicine." I'm Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. I'm Terry Gross back with Dr. Kevin Fong, author of the new book, "Extreme Medicine." It explains what doctors have learned about how our bodies work and how to save lives through treating patients exposed to extreme cold, heat, trauma and to the extreme conditions of outer space and the deep sea.

Dr. Fong is the founder of the Center for Altitude, Space and Extreme Environment Medicine at the University College of London, where he's also a professor of physiology. He's an anesthesiologist and is trained in intensive care medicine.

One of the chapters in your new book is about what happens to the body in frigid - in just like extreme cold. So you juxtaposed two stories. One is the story of what happened to Robert Falcon Scott, an explorer who froze to death in Antarctica in 1912 with the survival of a 29-year-old woman who was under the ice in frozen water for 80 minutes before she was even rescued and her heart had stopped beating. It's an incredible story. But let's just start...

FONG: Yeah, it truly is.

GROSS: Let's start in Antarctica. What happens to the body? What happened to Robert Falcon Scott's body when he froze to death?

FONG: So Falcon Scott's expedition, so in 1912, he takes his polar party of five men to the South Pole. And the reason that I was interested in that story was because, you know, it shows you how far we've come in a very short space of time. You know, at the start of the 20th century, the maps of the world still had white space, space where no human foot had ever trodden, and that included the South Polar Region and some of our highest mountain and our deepest oceans, let alone, the endless skies. So Scott's out there in 1912, walking back from the South Pole, having failed to win the race to the Pole; that race has been one by the Norwegian team led by Roald Amundsen, and they run into trouble. They run into a huge storm and he, with the remaining three surviving members of the expedition party, find themselves in a tent freezing to death.

So within each cell, nearly every single cell in our body are these little organelles called mitochondria, which are the powerhouses of the cell. They are the sources of power of our life, really and they're like biological batteries. And they work very, very crudely by separating charge across membranes really like an electrical battery does, you know, the sort you'd put in your flashlights at home. And so as the - as Scott gets colder and colder, those biological batteries start to run down and he can no longer maintain this sort of disequilibrium with the environment around him. He can no longer be this blazing furnace of life. And so, you know, finally and inextricably, he becomes like the wasteland around him, just no more energetic than the physical landscape in which he is and freezes to death.

GROSS: Well, and another thing that's happening to the body as the body is freezing is that the blood vessels are constricting. Why are they constricting and what impact does that have on the body?

FONG: So just before you freeze to death, you mount this sort of, you know, final effort to try and save your life. And so you try and centralize the heat to the core of your body. Your blood vessels constrict to try and stop you losing, you know, heat from your periphery, from your arms and from your legs. And then you try and get your hairs to stand on end what you do it's one of the reflexes we have. So your hair stands on end trying to trap an extra layer of air to insulate your body, so to try and trap an extra layer of air close to your skin to insulate your body. But, you know, all of this is your body sort of mounting its last-ditch attempts to keep itself alive. It does everything it can. It shivers hard to try and generate extra heat. It, you know, get your hair standing out on end trying to trap that layer of heat.

But all of this is really, you know, in the supposition that you can do something to change your environment to stop this process continuing, it's to buy you a bit of extra time. But in the case of Scott in that tent in 1912, there is no time to be bought. There is no rescue and so all of those efforts, all of those efforts to keep him alive are kind of in vain.

GROSS: So let's compare this to an incident in 1999 where a woman nearly froze to death and amazingly didn't. Two women and a man are skiing in Norway. A 29-year-old woman on the ski trail follows through the ice, ice over a stream. She falls into the freezing water. She's trapped there for 80 minutes until people come and pull her out. And then she first has to get to some kind of, you know, medical situation. Her heart had stopped beating. She didn't have a pulse. How is her body able to survive, considering in some, I mean can't you say she was technically dead?

FONG: Well, I mean certainly she was at the state at which she was she'd be indistinguishable, really, from someone who was dead. Her heart wasn't beating. She wasn't breathing. She was blue, cold and lifeless and you would've had to look extraordinarily hard to find any, any signs that she was alive at all. But, but, incredibly, despite the fact that her heart stopped for perhaps nearly three hours, she was resuscitated successfully. And this then is the story of Anna Bagenholm, who is a remarkable, remarkable woman.

So she was a junior doctor in 1999 and think about 29 years old, with two of her friends skiing in the northern mountains of Norway, so up in the Arctic Circle. And I think it was one of the first days of eternal sunshine, the start of the Arctic summer. And she catches an edge on her ski, goes headlong into a hole in some ice covering a stream and into that water, And they take a long time to get her out of there. And they know, they know because all of them are doctors. They know what's at stake here. They know that she'll freeze to death if they leave her in that position, but there is no one around to help them. The ski patrol are over an hour over the other side of the mountain. The nearest helicopter rescue is over an hour away flying time. And by the time they get her out of that ice - and I've spoken to her boyfriend who' one of the party, you know, when they retrieved her from the ice they said she's blue and she's lifeless and at that point they thought all they were going to achieve there was to retrieve the body of a dead friend. Nevertheless, they started to resuscitate her.

And they resuscitate her and continue resuscitating until the helicopter arrives. Now the helicopter can't land so it throws down a winch and they take her aboard the helicopter. And this is maybe an hour after her heart has first stopped. On the helicopter now, they continue to resuscitate her, even though it's another hour's flight back to Tromso, which is the nearest major hospital in that region. And so when they arrived to through front doors of the hospital, her heart has not beaten for the best part of two hours, maybe two hours, actually. And that's to a clinician, to a doctor, that's an incredible thing to hear that you have someone who arrives and you're being told that her heart had been beaten for, you know, maybe two hours, and that question you ask is, is it worth us trying to resuscitate her here?

And, you know, in clinical practice for me, when that happens, when you're called to see someone who is in cardiac arrest whose heart had stopped, almost the first thing you ask is well, how long? How long has it been? How long has it been since that heart stopped? And if someone tells you it's been more than about half an hour, you're pretty pessimistic about your chances of getting someone back alive. And yet for her, she's been down now for two hours and they still decide to proceed - which is, I don't know if heroic is the right word but it's an incredible decision. That they're hoping, they have one last hope and that is that the thing that's stopped her heart, the thing that is killing her, has also protected her, has protected her brain from the starvation of oxygen that it suffered. And they know that this is possible, they know that for people who come in at very low temperatures there is a chance of resuscitating them, even after extended periods of time, if they've been cold enough. Now...

GROSS: Why is that? Is the refrigeration of your body kind of keeping it fresh in a way, in a way that it would food?

FONG: So that's right. So the cold, the hypothermia is a double-edged sword here, because it conspires to run the batteries of life down, really in a way. And that's what stops your heart, you know, that's what leads to cardiac arrest. But also it protects the brain. So although it kills you, it smears out the dying process. And death, you know, we think of death as being a moment in time but actually, it is a process. And that process is usually, you know, relatively quick. It's completed in a few minutes under normal conditions. But here with these extremes of cold, you know, and her core temperature is 13.7 degrees Celsius, I think, when she arrived. So, you know, our normal core body temperature now is 37 degrees, both of us. It's within plus or minus about .2 degrees of that. So her core temperature is incredibly low and what that does biologically is it takes the process of death and it smears it out over seconds and extends it to minutes. And in her case they hope that it has smeared out to be hours long, long enough that they might intervene, restore the supply of oxygen to her brain, start her heart again and get someone back who resembles the person she was before the accident.

GROSS: And they had to warm her blood and warm her body. Would you explain how they did that?

FONG: Yes. And I mean that's a fascinating part of the story, really because, you know, when we get someone into our ER rooms who need resuscitating, you know, you stick them on the gurney and you get to work in the resuscitation base. But they had the presence of mind to know that that wasn't going to be enough. They knew that they needed to re-warm her very quickly if they were to have any chance. And so they took her past the ER straight up to the operating theaters and they plugged her into a heart-lung bypass machine, the sort of machine that you would use to do open-heart surgery. And they do that because they know that, you know, there's no point in sticking warm blankets on top of her or giving her warm fluids. That's not going to be enough. They need to raise her whole body, you know, I guess 50- to 60-odd kilograms of body up through to, you know, about 20 degrees Celsius of temperature. And to do that they're going to have to remove the blood from her body with this bypass machine and warm it up outside the body inside this machine and then send that back into her body in the hope that that can resuscitate her. And so that's what they do. They do effectively; they do a bit of bypass surgery on her. They plug tubes into her great veins and her major arteries and re-circulate her blood out of her body into a machine that is capable of warming up very quickly. And three hours after her heart had first stopped it begins to beat again for the first time.

GROSS: And after a very long period of several years' worth of, you know, slow recovery and physical rehab, she's skiing again and working at this hospital that saved her life.

FONG: She's truly remarkable. And I've come to know Anna quite well. And indeed, you know, if you were talking to her now you would have no sense of the ordeal that she's been through. She is an incredibly robust and impressive individual. And she feels it's her duty to tell this story because she thinks that particularly to other clinicians, to other doctors, because she says, you know, it's an example of where the limits lie. She feels that people should know, should have the courage to try in these situations and not just be fatalistic about what the outcome would be. Because, you know, there are many people who wouldn't have tried as hard in that situation. There are many people who would've given up much sooner than this team did and yet, they continued. And today you have a woman who is a fully qualified doctor who is out there, you know, doing her job.

GROSS: If you're just running us, my guest is Dr. Kevin Fong. He's the author of the new book "Extreme Medicine." Let's take a short break here and then we'll talk some more. This is FRESH AIR.

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GROSS: If you're just running us, my guest is Dr. Kevin Fong. He's the author of the new book "Extreme Medicine." And he's the founder of the Center for Altitude, Space and Extreme Environment Medicine at University College, London, where he teaches physiology. He's also a consultant in anesthesia and intensive care medicine.

Your new book is about extreme medicine. And you've practiced extreme medicine, you studied extreme medicine, you teach extreme medicine. What's the most extreme medical problem you've been called on to treat?

FONG: Gosh. That's very difficult to know. There have been many, many, many cases over time that have changed the way I've looked at things or in which, you know, people have survived unexpectedly. I think there's one particular episode in the book that I write about of a young man who, you know, we really thought there was no chance that he could survive.

He'd come to us very, very sick and at the point which I was called to see him he'd had repeated cardiac arrests and we'd had to defibrillate him, so shock his heart, over and over again just to keep him going. And we thought there was some surgical disaster going on in his abdomen and so we called the surgeon. The surgeon said, well, look, you know he's not going to survive; I don't think there's anything we can do here.

But he was so young we thought, well, we've got to try and do something. And all the time we're having these conversations here in the background all you're hearing is the paddles charging up and someone delivering another shock. And every time they do that you wonder whether or not the heart's going to restore to a rhythm that's compatible with life.

And so it was one of those days when I thought, you know, we're not going to win here but we have to try as hard as we possibly can. You know, he was very young; he was a teenager. And we took him to theater and I think that was the toughest run I've ever had, actually. You know, it got to the point where I wasn't even really that focused on the anesthetic because, you know, all I was doing was repeatedly resuscitating this patient, shocking them every couple of minutes.

You know, and it got to the point where it was the early hours of the morning and the heart would run into an abnormal rhythm again. And I wouldn't even do that thing of telling the surgeon to stand clear very loudly and have everyone stand clear. I would just nod at the team, the team would nod at me, they'd step back from the table and I'd shoot the shocks again.

But, you know, the surgeons found the problem. We snipped out this loop of bowel that had died and sewed the patient up. We got him back to the Intensive Care Unit and we had a very rocky 24 hours but things got better and better and better and he walked out of the hospital, you know, a couple of weeks later. And when you see that happen once, you kind of have the hope that you might see it happen again.

GROSS: Does that help get you through all the times when it doesn't happen and you lose the patient?

FONG: It makes a lot of it worth it. I think, you know, you need to be reminded at times it is worth trying. You can develop this sort of nihilism. I think I did very early on in my career, I sort of developed a sort of bit of nihilism about the whole thing. You know, I did really wonder whether it was a ridiculous thing to be pouring this much resource into, you know, patients who were this sick.

And I did wonder that there might be better, easier fights to have where we might do more good with less resources. But, you know, that's kind of what the book is about for me. It's about the fact that the edges of medicines, at the limits of what we can do, we're still exploring. We're still exploring the human body and what medicine can do in the same way that the great explorers in the 20th century and every age before them explored the physical world.

And the two - actually, when you look at them in that way, you know, they can't be divorced from one another. These are feats of exploration with the same goal in mind. You're taking this headlong plunge into the unknown hoping only that good fortune and survival might lie in wait. And so I think in writing the book I was able to sort of reconcile these sort of disparate strands in my life and, you know, I was quite pleased to have done so.

One of my colleagues from The Guardian when he read the book said is this book therapy for you, Kev?

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FONG: And I kind of - it probably was, you know.

GROSS: Having been exposed to so much death and near death and to so many bodies that have been subjected to extremes of trauma and temperature and depths of water and so on, has it made you think of your body as more vulnerable or more resilient?

FONG: I think both, actually. I think over time I've come to marvel at the human body's simultaneous fragility but the resiliency it can show right at the edge just before it finally gives up the ghost, you know, how resilient it can be. And, you know, it's a weird thing to have coexisting, I think, in the same spectacle, you know, fragility and resilience but that's what I've come to see of the human body.

And in that I think is its intrinsic beauty. You know, that it's able to mount this massive, massive fight when everything else looks like it's lost. And it allows us to operate and launch even more ambitious interventions.

GROSS: Well, Dr. Kevin Fong, thank you so much for talking with us.

FONG: Thank you.

GROSS: Dr. Kevin Fong is the author of "Extreme Medicine." You can read the introduction on our website freshair.npr.org. This is FRESH AIR.